Anda di halaman 1dari 10

Medical and surgical management of nasal polyps

Paraya Assanasen, MD, and Robert M. Naclerio, MD

Sinonasal polyposis represents a chronic inflammatory condition of unknown etiology. It is often associated with systemic
diseases and is characterized by nasal obstruction, reduction
in sense of smell, infection, and impaired quality of life.
Endoscopy has enhanced the diagnosis and management of
nasal polyps. The initial approach is medical management.
Medical therapy consists of administration of intranasal
steroids or a short course of systemic steroids. Other medical
treatments considered are use of antibiotics, leukotriene modifiers, and acetylsalicylic acid avoidance. Surgical removal is
performed for nonresponders to medical management. The
purpose of surgery is to restore the nasal physiology by
making the nose free from nasal polyps and allowing drainage
of infected sinuses. With a computer-assisted navigation
system and power instrumentation, surgical removal of polyps
can be done more easily and accurately with fewer complications than previously. Medical therapy after surgery is essential
for preventing recurrence. Curr Opin Otolaryngol Head Neck Surg 2001,
9:2736 2001 Lippincott Williams & Wilkins, Inc.

Section of OtolaryngologyHead and Neck Surgery, The Pritzker School of


Medicine, The University of Chicago, Chicago, Illinois, USA.
Correspondence to Robert M. Naclerio, MD, Professor and Chief, Section of
OtolaryngologyHead and Neck Surgery, The University of Chicago, 5841 S.
Maryland Ave., MC 1035, Chicago, IL 60637, USA; e-mail:
rnacleri@surgery.bsd.uchicago.edu

Current Opinion in Otolaryngology & Head and Neck Surgery 2001,


9:2736
Abbreviations
CT
ESS
FPND
GM-CSF
RANTES

computed tomography
endoscopic sinus surgery
fluticasone propionate nasal drops
granulocyte-macrophage colony-stimulating factor
regulated on activation, normal T cell expressed and secreted

ISSN 10689508 2001 Lippincott Williams & Wilkins, Inc.

Nasal polyposis is an inflammatory chronic disease of the


upper respiratory tract of unknown etiology. The prevalence varies from 1 to 5% [1]. Nasal polyps usually are
manifested after the age of 20 years, with affected men
outnumbering women two to one. The term sinonasal
polyp usually refers to outgrowths of tissue into the nasal
cavity. The most common site of origination of nasal
polyps is the anterior ethmoid region (Table 1) [2].
Radenne et al. [3] found that nasal polyps, besides
causing nasal obstruction, hyposmia, and recurrent infection, impaired the quality of life more than did perennial
allergic rhinitis. Whereas 71% of patients with polyps
have asthma [4], there is now evidence that patients with
nasal polyps are at an increased risk for the development
of asthma [5]. Lamblin et al. [6] found that patients with
nasal polyps and asymptomatic bronchial hyperresponsiveness had an eosinophilic bronchial inflammation
similar to that observed in asthmatic patients with nasal
polyps, whereas patients with nasal polyps without
bronchial hyperresponsiveness did not have eosinophilic
lower airway inflammation. These data suggest that
eosinophilic inflammation in patients with nasal polyps
may precede the development of asthma.
Other conditions associated with nasal polyps include
chronic rhinosinusitis, aspirin intolerance, and cystic
fibrosis (Table 2). In one recent study, the prevalence
of nasal polyps in 211 adult patients with cystic fibrosis
was 37% [7].

Etiology
Several mechanisms have been proposed for the formation
of nasal polyps. These include allergy, infection, autonomic imbalance, abnormal transepithelial ion transport,
mucopolysaccharide abnormality, enzyme abnormality,
mechanical obstruction, and epithelial rupture. Although a
positive skin test for aeroallergens has commonly been
associated with polyps, there has been little evidence for
the implication of IgE-mediated allergy in their formation.
In a recent study, high percentages (40%) of patients with
severe nasal polyposis showed an immediate skin reaction
to Candida, compared with controls (1%) [8]. Furthermore,
another recent prospective study showed that 81% of nasal
polyp patients had positive intradermal food test results,
compared with 11% of controls [9]. Although these findings present associations, the relevance to the pathogenesis of nasal polyps is unknown.
Clinical as well as experimental studies indicate that
nasal polyp formation and growth are activated and
27

28 Nose and paranasal sinuses

Table 1. Origin of polyps in 200 consecutive patients


Site of origin

Patients, %

Uncinate, turbinate, infundibulum


Face of bulla, hiatus semilunaris, infundibulum
Frontal recess
Between bulla and middle turbinate
Inside bulla
Supra- and retrobullar recess
Posterior ethmoid (superior meatus)
Middle turbinate
Secondary sinuses affected
Maxillary sinus (mucosal swelling)
Frontal sinus (mucosal swelling)
Sphenoid sinus

80
65
48
42
30
28
27
15
65
23
8

Data from Stammberger [2].

perpetuated by an integrated process of mucosal epithelium, matrix, and inflammatory cells, which, in turn,
may be initiated by both infectious and noninfectious
inflammation [10]. This underlying pathology may lead
to increased interstitial fluid pressure and obstruct blood
flow in nasal polyps, resulting in edema and distension
of stroma. If nasal polyps obstruct sinus drainage, subsequent infection can cause more venous stasis and
mucosal edema, leading to a self-perpetuating cycle.
The inflammatory process in polyps continues to be examined. Expression of RANTES (regulated on activation,
normal T cell expressed and secreted) and interleukin-5,
cytokines with eosinophil chemotactic properties, is
substantially increased in nasal polyps compared with
normal mucosa, with no substantial differences in their
expression between polyps from patients with and patients
without allergies [11]. Both cytokines had a significant
correlation between their expression and the number of
either total or activated eosinophils. In addition, overproduction of eosinophil survival factors has been shown to
delay apoptosis of eosinophils, resulting in tissue
eosinophilia [12]. Nakagawa et al. [13] found that edematous morphology, the infiltration of eosinophils, and the
expression of fibronectin, one of the extracellular matrix
proteins, were correlated with the size of nasal polyps.
Their data suggest that interaction between eosinophils

Table 2. Conditions associated with nasal polyposis


Allergic and nonallergic rhinitis
Allergic fungal sinusitis
Aspirin intolerance (acetylsalicylic acid triad: nalsal polyps, asthma,
aspirin intolerance)
Asthma
ChurgStrauss syndrome (fever, asthma, eosinophilic vasculitis,
granuloma)
Cystic fibrosis
Immunodeficiency
Primary ciliary dyskinesia
Kartagener syndrome ( chronic sinusitis, bronchiectasis, situs
inversus)
Young syndrome (sinopulmonary disease, azoospermia, nasal
polyps)

and fibronectin may play a role in edema formation, which


contributes to the growth of nasal polyps. Furthermore,
vascular endothelial growth factor was found to be more
intensely expressed in nasal polyps than in control nasal
mucosa [14]. This suggests that vascular endothelial
growth factor could be involved in induction of angiogenesis and increased microvascular permeability.
Building on the old observation that polyps lack neural
elements, Gungor et al. [15] examined the capsaicininduced levels of neuropeptides in nasal secretions of
subjects with and subjects without nasal polyps.
Subjects with nasal polyps responded poorly to capsaicin
stimulation, suggesting depletion of neuropeptides.
Apoptosis (programmed cell death) mediated through
the Fas/Fas-ligand system is essential in regulating
immune function, developing organs, and conferring
immune privilege. Fang and Yang [16] found overexpression of Fas-L protein on nasal polyps compared with
nasal mucosa. Fas-L-positive cells were localized to the
epithelial layers of cystically dilated glands and the
ingrowing epithelium of nasal polyps. Fas-L may play
an important role in the pathogenesis of polyps by
prolonging cell survival.
There is evidence that persons carrying the HLA-DR7DQA1*0201 and -DQB1*0202 haplotype have two to
three times higher odds for developing nasal polyps than
do controls [17]. These results and the development of
nasal polyps in genetically transmitted diseases such as
cystic fibrosis and primary ciliary dyskinesia indicate
that genetic etiology may play a role in the formation of
nasal polyps.
In patients with aspirin intolerance, the arachidonic acid
pathway appears to play a part, with markedly elevated
peptidoleukotrienes being found in nasal polyps
compared with adjacent normal mucosa of individuals
with aspirin intolerance and of controls [18]. Nasal
polyps of persons with aspirin intolerance show a
substantially lower release of prostaglandin E2 than does
the normal mucosa of persons with aspirin intolerance
and controls [18]. In addition, aspirin-intolerant patients
showed elevated basal levels of peptidoleukotrienes and
reduced basal levels of prostaglandin E 2 in isolated
blood cells, compared with a healthy control [18,19].
Furthermore, inadequate cyclooxygenase-2 regulation
may be involved in the pathogenesis of aspirin-intolerance, because cyclooxygenase-2 mRNA expression in
nasal polyps from the aspirin-intolerant patient group
was markedly and significantly lower than that in polyps
from the aspirin-tolerant patient group and individuals
with a healthy nasal mucosa [20]. These studies suggest
that drugs that alter the arachidonic acid pathway may
cause polyps in patients with aspirin intolerance.

Nasal polyps Assanasen and Naclerio 29

Polyps seem to be a heterogeneous group of entities


with a common end point. As our understanding of
inflammation increases, we can better describe the
inflammation within polyps. The main question is
whether studying inflammation in polyps, an end stage
of disease, will determine its cause or provide insights
for therapeutic advances.

Figure 1. Management plan for evaluation and management of


nasal polyposis
Evaluation

Symptoms suggesting nasal polyps

Histology
Polyps are covered by pseudostratified columnar epithelium with some areas of squamous metaplasia, basement
membrane thickening, and a reduced number of mucous
glands. The epithelium may contribute to increased
mucus secretion [21]. Nasal polyps contain significantly
more eosinophils, neutrophils, and plasma cells than does
the nasal mucosa [22]. The presence of atopy or T-helper
type 1 or 2 predilection does not determine either the
type or the extent of cellular infiltration of nasal polyps.
Flow cytometric analysis showed that there were no
significant differences in the frequencies of lymphocytes
and lymphocyte subsets (CD1+, CD2+, CD3+, CD5+,
CD7+, CD4+, CD8+, CD10+, CD19+, CD20+, and
HLA-DR+ cells), including CD4/8 ratios, between the
nasal mucosa and polyps [22].
The mechanisms responsible for selective accumulation
of eosinophils in polyps are unknown. Nasal polyp
fibroblasts could play a role in the recruitment of
eosinophils through the release of eotaxin [23],
RANTES, and granulocyte-macrophage colony-stimulating factor (GM-CSF) [24]. Several cytokines (interleukin-4, -5, -6, and -8, tumor necrosis factor-, GMCSF, RANTES) have been shown to be upregulated in
nasal polyps, suggesting that resident structural cells can
produce a number of molecules to attract inflammatory
cells and prolong their survival [11,25]. These inflammatory cells themselves can also produce cytokines such as
interleukin-3, tumor necrosis factor-, and GM-CSF,
which recruit more inflammatory cells in an autocrine
fashion [25]. Adhesion molecules have also been studied
in nasal polyps, and it was found that vascular cell adhesion molecule is upregulated [26].

Evaluation of the patient


History and physical examination

The evaluation of nasal polyps begins with a history


(Fig. 1). The most common symptom is nasal obstruction. Hypoxia, hypercapnia, snoring, sleep disorders, and
an increased risk of hypertension may develop in
patients with nasal polyposis [27]. Polyps may obstruct
airflow to the olfactory cleft and lead to loss of the sense
of smell. In addition, patients may have symptoms of
sinus obstruction. A complete ear, nose, and throat
examination should be performed with special focus on
the nasal cavity. Nasal polyps are uncommon in children, and their presence should prompt evaluation for

Examination

Essential
Symptom history
Rhinoscopy/nasal
endoscopy

Strongly
consider
CT scan

Consider
Allergy testing
Culture, biopsy,
special stain
Sweat/genetic testing
Pulmonary function
Aspirin challenge
Excluding sinister
pathology

Management

Essential
Intranasal corticosteroid
for 46 weeks
Response

Consider
Antibiotics
Aspirin desensitization

No response
Systemic
corticosteroids
Response

Continue intranasal
corticosteroids

No response

After surgery

CT scan and surgery

Published with permission [42].

cystic fibrosis. A unilateral nasal polyp should raise the


suspicion of an inverted papilloma or tumor in adults, or
of dermoid cysts, encephaloceles, and gliomas in children. Examination of the oral cavity may show polyps
behind the free margin of the soft palate in cases of
antrochoanal polyps or postnasal drips that are related to
coexistent infection.
Nasal endoscopy

Nasal endoscopy provides excellent visualization of


polyps, especially of small polyps in the middle
meatus. It also shows nasal polyps originating from
contact areas in middle meatus and nasal anatomic
abnormalities. Culture of the discharge and a biopsy
can be performed under endoscopic guidance. Cultures
from the middle meatus or osteomeatal complex area
have been shown to correlate with cultures obtained
from within the sinuses [28].

30 Nose and paranasal sinuses

Other diagnostic tests

Table 4. Objectives of management of nasal polyposis

Other investigations include allergy testing, a pulmonary


function test, biopsies, a sweat chloride test or genetic
testing for detection of cystic fibrosis, aspirin intolerance
testing, and fungal stains and cultures (Fig. 1). Computed
tomography (CT) scanning shows the extent of disease.
CT scan is essential in cases of unilateral disease, failure
of medical management, and when complications are
suspected. CT scanning is best performed after medical
management to delineate the chronic disease component.
CT scanning is superior to magnetic resonance imaging in
the depiction of bone details [29]. Magnetic resonance
imaging is advisable when a skull base erosion is noted
adjacent to an area of sinus opacity. It can differentiate
between sinus disease eroding the skull base and a
meningocele or encephalocele. Magnetic resonance
imaging also helps to differentiate the tumor from
retained secretions and secondary inflammatory disease.

Reestablish nasal airways and nasal breathing


Minimize symptoms
Improve sense of smell
Treat coexisting diseases
Improve quality of life
Prevent complications

A staging system for rhinosinusitis allows comparison


among published studies. Several radiography-based
systems have been proposed. The most commonly
used system is that described by Lund and Kennedy
[30] and Mackay and Lund [31]. It has also been
suggested that endoscopic appearance of the sinonasal
cavity (Table 3) [31] and the patients symptom scores
should be recorded preoperatively and 3, 6, 12, and 24
months postoperatively [30].

Medical management
Nasal polyps are primarily diseases to be managed
medically. Although some cases require surgery, aggressive medical therapy before and after surgery is needed.
The aim of the treatment is to restore ventilation and
sinus drainage as well as to prevent recurrence of the
disease (Table 4) [32].
Antibiotics

Nasal polyps can cause obstruction of the sinuses,


resulting in infection. Treating infection with antibiotics
may prevent further polyp growth and lessen bleeding
during surgery. Antibiotic therapy should be directed
toward Staphylococcus species, Streptococcus species, and
anaerobes, which are common organisms in chronic
sinusitis. Pseudomonas aeruginosa may colonize the sinus
cavities in patients who have cystic fibrosis and those

Table 3. Grading of nasal polyps

No polyps
Polyps restricted to middle meatus
Polyps below middle turbinate
Massive polyposis
Data from Mackay and Lund [31].

who have had prior surgery. In immunocompromised


hosts or those who have been on several prior courses of
antibiotics, direct endoscopic culture or antral puncture
is recommended to exclude unusual or resistant organisms. Interestingly, roxithromycin, a macrolide antibiotic, has been reported to inhibit fibrosis and prevent
the progression of nasal polyposis [33].
Corticosteroids
Mechanisms of corticosteroid treatment

Staging system

Endoscopic appearance

Data from Lildholdt and Mygind [32].

Score
0
1
2
3

Corticosteroids have a broad range of anti-inflammatory


effects. Topical steroids have been shown to reduce the
number of lymphocytes in nasal polyp tissue and to
inhibit the synthesis of cytokines [34]. Topical steroids
also reduce the total number and activation status of
eosinophils [35]. Tingsgaard et al. [36] showed that topical
treatment with budesonide substantially reduced the
density of eosinophils and the endothelial vascular cell
adhesion molecule expression in polyps. In a doubleblind, placebo-controlled trial, Hamilos et al. [37]
studied the effect of 4-week treatment with intranasal
fluticasone propionate on inflammatory parameters in
nasal polyps. Fluticasone treatment significantly reduced
the number of major basic protein (MBP)+ and EG2+
eosinophils, CD4+ T lymphocytes (Fig. 2), and interleukin-4 and -13 mRNA+ cells, and the expression of Pselectin. In contrast, fluticasone did not significantly
reduce the expression of endothelial vascular cell adhesion molecule or the number of tumor necrosis factor- or
interleukin-1 mRNA+ cells in the polyps.
Jahnsen et al. [38] investigated the expression of
chemokines in nasal polyps and found that mRNA
expression for eotaxin, eotaxin-2, and monocyte-chemotactic protein-4 was significantly increased in nasal polyps
compared with the turbinate mucosa in the same
patients, or in control subjects. Polyp tissue had strong
chemotactic activity for eosinophils. When patients were
treated systemically with glucocorticosteroids, the mRNA
level in the polyps was reduced to that found in the
turbinate mucosa. Rudack et al. [39] investigated the
effects of steroid (prednisolone) on eosinophils and their
associated cytokines in nasal polyps in vitro. Prednisolone
at concentrations of 10 3 to 10 2 mol/L significantly
reduced the number of eosinophils, the total number of
vital cells, GM-CSF, and interleukin-5 protein levels in

Nasal polyps Assanasen and Naclerio 31

Figure 2. Changes in inflammatory cell infiltrate in nasal polyps after intranasal fluticasone versus placebo treatment for 4 weeks

Placebo

22
20
18
16
14
12
10
8
6
4
2
0

Fluticasone

Placebo

14
+
+
+

+
+

EG2+ Eosinophils

MBP+ Eosinophils

Fluticasone treatment significantly reduced the number of


major basic protein (MBP)+ eosinophils (P = 0.02), EG2+
eosinophils (P = 0.007), and CD4+ T cells (P = 0.03)
compared with numbers before treatment. Pre, before treatment; Post, after treatment. Published with permission [37].

10
8

+
+
+

+
+

+
+

10

10
8
6
2

supernatants, whereas interleukin-3 synthesis was not


diminished. These data suggest an important role of
cytokines in the pathogenesis of polyps.
Apoptosis is an important process that reduces the number
of inflammatory cells and hence aids in the resolution of
inflammation. In a double-blind, placebo-controlled test,
Saunders et al. [40] studied the effect of treatment with
fluticasone propionate aqueous nasal spray in nasal polyposis on indices of cell death and proliferation measured in
vivo. They also studied the effect of dexamethasone at
increasing doses on the same parameters in vitro.
Corticosteroids induced apoptosis in inflammatory cells in
human nasal polyps only in vitro but not in vivo. The
difference in results probably relates to differences in the
dose of steroid, in the experimental setting, in the drug
distribution (topical vs systemic), or in metabolism in vivo.
The association between induction of apoptosis and the
regression of nasal polyps is unproved.
The refractoriness of symptoms and mucosal inflammation to oral steroids in patients with nasal polyps may
indicate steroid resistance. Potential mechanisms for
steroid resistance in nasal polyps may involve an alteration of the cellular response to steroids or overexpression of a glucocorticoid-resistant receptor (GR) [41].
Intranasal corticosteroids

Topical corticosteroids have been the drugs of choice for


nasal polyposis (Fig. 1) [42]. If surgery is subsequently

Post

Pre

Post

5
Pre

12

+
CD8+ T cells

CD4+ T cells

15

12

25
20

Fluticasone

Pre

Post

Pre

Post

required, long-term postoperative treatment with corticosteroid nose sprays increases the time to recurrence.
Some patients with nasal polyps do not respond to
topical steroids. This may be due to two possible mechanisms. First, the underlying cause of nasal polyps, such
as cystic fibrosis or primary ciliary dyskinesia, is unresponsive to corticosteroids. Second, nasal congestion by
nasal polyps may cause an inadequate intranasal distribution of the topical steroid spray [43]. Recently, application of steroid nasal drops has been proposed as an
alternative delivery system. It is recommended that
these be used in the head-inverted position (Moffits
position) to provide maximum local activity in the
middle meatal area [44]. The systemic bioavailability
of fluticasone nasal drops is lower than that of nasal
spray (0.06 vs 0.5%) [45]. However, one study showed
that 6-week treatment with recommended doses of
betamethasone topical nasal drops in 11 patients with
nasal polyposis had systemic corticosteroid activity and
suppressed the hypothalamo-pituitary-adrenal axis [46].
Local intralesional injection of steroids is also effective,
but rare complication of visual loss can occur.
Systemic corticosteroids

Short-term treatment with systemic corticosteroids is an


alternative method of inducing remission and controlling
nasal polyps. In experimental sinusitis in rabbits, intramuscular injection of steroid inhibited polyp formation
and growth of pathogenic bacteria in the sinuses [10]. In
contrast to nasal steroids, systemic corticosteroids can

32 Nose and paranasal sinuses

reach all parts of the nose and sinuses, including the


olfactory cleft and middle meatus, and improve the sense
of smell better than topical steroids [32]. Additionally,
short courses of systemic steroids can be used for nasal
polyposis to open up nasal obstruction before therapy
with intranasal steroids, which results in improvement of
the intranasal spray distribution. Long-term treatment
with a low daily dose of oral steroids and intranasal
steroids in patients with aspirin intolerance and allergic
fungal sinusitis may be necessary.
Before surgery, oral steroids are typically given for about
3 or 4 days to shrink the polyps. Oral steroids are also
beneficial in asthmatic patients by reducing the
bronchial hyperreactivity, which can be exacerbated by
surgery. Care should be taken in administering oral
steroids to patients with diabetes mellitus, psychiatric
disorders, herpes keratitis, advanced osteoporosis, tuberculosis, glaucoma, and hypertension.
Other medications

The use of antihistamines and decongestants may


provide symptomatic relief but does not change the
course of the disease. Immunotherapy has been shown
to be beneficial in patients with allergic fungal sinusitis
[47] and may be useful in patients with recurrent polyposis. Leukotriene antagonists may provide benefits in
some patients who have aspirin intolerance [48].

Surgical management
Surgical removal of nasal polyps is indicated for patients
not responding adequately to medical management,
those with continued or recurrent infections, as well as
patients who are developing mucoceles or other complications of sinusitis. Patients with polyps and asthma may
benefit from surgery by reduction of one trigger for
asthma. All involved sinuses should be opened, in addition to the removal of polyps.
Correction of outflow obstruction promotes drainage and
leads to reversal of mucosal changes within the paranasal
sinuses. Denudation of bone, especially in the areas of
the maxillary and frontal ostia, should be avoided
because it may lead to granulation and osteitis, with
prolonged postoperative healing or stenosis.
Recent advances in endoscopic surgery involve computerassisted navigation and power instrumentation [49,50].
Patients with extensive polyp disease and those undergoing revision surgery may benefit from image-guided
surgery because the thoroughness of the surgery may be
improved and complications may be reduced [49].
Powered instrumentation with microdebriders minimizes
inadvertent mucosal trauma and stripping [51]. The
microdebrider can be used for removing nasal polyps or
other tumors in the sinonasal cavity without altering the

specimen for histopathology [52]. In 40 cases of endoscopic sinus surgery (ESS) performed with the microdebrider, patients who had at least a 5-month follow-up
showed rapid mucosal healing, minimal crust formation,
and a low incidence of synechiae formation [53].
The most important goals of follow-up care are prevention of synechiae and obstruction of ostia; restoration of
patency of the nasal and sinus cavity; prevention of
persistent inflammation, infection, and further polyp
growth; and stimulation of the development of normal
mucosa to replace the diseased tissue. Endoscopic
examination of the sinonasal cavity postoperatively has
been shown to provide prognostic information, which is
independent of the subjective reporting of symptoms by
patients [54]. Patients with abnormal endoscopic findings tend to have recurrent symptoms and a need for
additional surgery in the future [54]. Postoperative treatment with intranasal steroids is required because it
helps to slow the rate of recurrence of polyps.
Antibiotics are administered during acute healing. Small
recurrent polyps may be removed endoscopically or by
prescription of a short course of oral steroids. Some
groups of patients, ie, those with aspirin intolerance,
allergic fungal sinusitis, asthma, or cystic fibrosis,
require aggressive and extensive treatment and followup because of a high recurrence rate.

Results of medical and surgical therapy for


nasal polyps
Intranasal corticosteroids

Topical steroid therapy has been shown, in patients with


nasal polyps, to improve nasal blockage [5557], nasal
patency as measured by nasal peak flow [55,56,58], nasal
volume as measured by acoustic rhinometry [56], and
sometimes the sense of smell, and to prevent or delay the
recurrence of nasal polyps after surgery [55,58].
Steroid nasal drops have also been shown to be effective
in the management of nasal polyps [59,60]. In a doubleblind, placebo-controlled, multicenter study, Penttila et
al. [61] evaluated the dose-related efficacy and tolerance of fluticasone propionate nasal drops (FPND) in
the management of mild to moderate bilateral polyposis.
FPND at 400 g twice daily significantly reduced polyp
size and nasal blockage (Fig. 3) and improved the peak
nasal inspiratory flow and sense of smell. Significant
reductions in polyp size were not achieved with oncedaily administration, but clinical benefits were observed
for peak nasal inspiratory flow and nasal blockage and
for overall rhinitis symptoms (Fig. 3). FPND, 400 g
twice daily, was significantly more effective than 400 g
once daily. Both dosing regimens were well tolerated,
without any significant effect on mean serum cortisol
levels, and the overall incidence of adverse events was
similar to that for placebo.

Nasal polyps Assanasen and Naclerio 33

Systemic steroids

Systemic steroids reduce the frequency of all symptoms


and improve the sense of smell [62,63]. Damm et al. [64]
evaluated the efficacy of a combined (intranasal and
systemic) form of steroid therapy. A nasal budesonide
spray (0.2 mg/d) and an oral fluocortolone medication
with a daily reduction during a 12-day period (total dose,
560 mg) and a 20-day period (total dose, 715 mg), respectively, were administered. The combined short-term
steroid therapy significantly reduced the extent of chronic
polypoid rhinosinusitis on magnetic resonance imaging
(> 30%) in 50% of patients and diminished most sinusitisrelated symptoms in 80% of patients. The steroid effect
on polypoid masses was heterogeneous in different
anatomic areas, with the best reduction of inflamed
mucosa in the sphenoid, frontal, and maxillary sinuses.
This effect, however, was not seen in the anterior
ethmoid area, a key area for the development of polyps.
Leukotriene antagonist

Parnes and Chuma [65] evaluated the efficacy of a


leukotriene synthesis inhibitor (zileuton) and a
leukotriene receptor antagonist (zafirlukast) in controlling
sinonasal polyposis and its associated symptoms in 40
patients with sinonasal polyposis and sinusitis, without any
change in their standard therapy. Overall, 72% of patients
experienced subjective improvement after starting their
medication. Objective alleviation, or at least stabilization,
of sinonasal polyposis was seen in 50% of the patients.
However, this was a preliminary study without a control
group. Ulualp et al. [66] retrospectively studied the effect
of antileukotriene therapy for the relief of sinus symptoms
in patients with aspirin-triad disease who had undergone
previous sinus surgery. Fifty percent of patients had
improved symptom scores after antileukotriene therapy;
Figure 3. Percentages of patients showing improvements in
parameters specified on the abscissa after 12 weeks of treatment with fluticasone propionate nasal drops

60

Patients, %

50
40

Placebo
FPND 400 g od
FPND 400 g bid

**

**

Several authors reported the favorable outcome of ESS in


patients with chronic sinusitis or nasal polyps in both
short-term (average, 623 months) [6769] and long-term
(average, 3.77.8 years) follow-up [70,71]. More than 80%
of patients reported marked subjective improvement in
their symptoms. Sharp et al. [72] showed a significant
correlation between outcome of ESS at 2 years and the
preoperative CT scan score (Lund and Mackay system),
but the statistically most significant factor determining
the success or failure of surgery was the presence of a
systemic disease known to predispose to chronic rhinosinusitis. Mostafa et al. [73] retrospectively analyzed the
records of 100 patients with nasal polyposis and studied
various parameters including radiologic, intraoperative,
and bacteriologic data. They found that, among the
various parameters studied, maxillary antral involvement
of nasal polyps and positive bacterial cultures seemed to
be the most predictive criteria of recurrence.
Radenne et al. [3] evaluated the effect of management of
nasal polyps on the quality of life in 28 patients with nasal
polyps. The results demonstrated that nasal polyp treatment with either nasal steroids or endonasal ethmoidectomy significantly improved nasal symptoms and quality
of life. The use of quality-of-life measures as a new tool
for the evaluation of treatment efficiency in chronic
sinusitis and nasal polyps has been encouraged [74].

Overall rhinitis

There is also increasing evidence that management of


polyposis has a benefit for the lower airway. Senior et al.
[83] assessed the long-term impact of ESS in patients
with chronic rhinosinusitis and asthma at an average
follow-up of 6.5 years. Of 30 patients with asthma and
sinusitis, 27 (90%) reported that their asthma was less
severe than it had been before ESS. The average rate of
reported improvement increased from 49% at 1.1 years
after surgery to 65% at 6.5 years after surgery. Asthma

20
10
0
Nasal blockage

Surgery

Endoscopic sinus surgery has also been shown to lead to


significant improvement in total nasal resistance as
measured with rhinomanometry [75], in nasal volume by
acoustic rhinometry [76], in ciliary beat frequency
[77,78], in mucociliary clearance as measured by saccharin test [7880], and in olfaction as measured by
University of Pennsylvania Smell Identification Test
(UPSIT) testing [76,77,81,82].

30

Polyp size

17% of patients reported overall benefit from therapy,


despite no improvement in their symptom scores.
Findings on endoscopic nasal examination were consistent
with the reports of an overall benefit. These data suggest
that antileukotriene therapy may have benefits in patients
with sinonasal polyposis. However, further double-blind,
placebo-controlled studies are required for defining the
role of leukotriene- modifying agents.

Four hundred micrograms once a day (od) (n = 48), fluticasone propionate nasal
drops 400 g twice daily (bid) (n = 47), or placebo (n = 47). *P < 0.05, P < 0.01 vs
placebo. Adapted with permission [61].

34 Nose and paranasal sinuses

attacks declined in 20 of 27 patients (74.1%).


Approximately half reported less inhaler usage, and
nearly two thirds reported less oral steroid use. Other
studies [84,85] also showed favorable results of ESS in
the management of asthma.
The aspirin triad (nasal polyposis, asthma, and sensitivity to aspirin) is a well-recognized clinical entity.
Amar et al. [86] made an outcome analysis retrospectively in acetylsalicylic acid triad patients who had
undergone ESS. The control group consisted of 22
patients with chronic sinusitis, with or without asthma,
who had also undergone ESS. Acetylsalicylic acid triad
patients had more extensive involvement of the
sinuses radiologically. Furthermore, acetylsalicylic
acid triad patients underwent a larger number of
repeat operations, suggesting that these patients
respond less well to surgical intervention. Nakamura et
al. [87] evaluated the surgical management of sinusitis
in 22 patients with aspirin-induced asthma. Sinus
surgery reduced asthma symptoms in 20 patients
(90.9%) and improved the pulmonary function test 1
year after surgery. Three of five patients (60%) who
used systemic steroids were able to eliminate or
reduce their doses, and eight of 17 patients (47.1%)
who were using inhaled topical steroids reduced their
doses. These results strengthen the beneficial effect
of sinus surgery on asthma symptoms even in patients
with aspirin-induced asthma.

Conclusions
Sinonasal polyps represent a diffuse inflammatory
process that probably has multiple causes. The
management of nasal polyps remains primarily
medical, with oral and topical nasal steroids. Systemic
steroids can reduce rhinitis symptoms, improve the
intranasal distribution of topical steroids and the sense
of smell, facilitate nasal surgery, prevent the recurrence of polyps after polypectomy, and can be used as
a substitute for simple polypectomy. Topical corticosteroids have been shown to reduce polyp size and
rhinitis symptoms as well as to delay the recurrence of
polyps after surgery. Topical steroids can be combined
with systemic corticosteroids in severe cases. Nasal
drop formulations of corticosteroids may improve their
efficacy by providing a better drug distribution and
penetration into the osteomeatal area as compared
with nasal sprays. Other medical therapies such as the
use of leukotriene antagonists may be helpful but
need further study. Surgery is indicated in patients in
whom medical management fails or who have complications. The postoperative care needs to be intensive
so that recurrence is delayed.

Acknowledgment
Supported in part by an Anandamahidol King Scholarship.

References and recommended reading


Papers of particular interest, published within the annual period of review,
have been highlighted as:

Of special interest
Of outstanding interest

Settipane GA: Epidemiology of nasal polyps. Allergy Asthma Proc 1996,


17:231236.

Stammberger HR: Rhinoscopy: endoscopic diagnosis. In Rhinitis:


Mechanisms and Management. Edited by Naclerio RM, Durham SR,
Mygind H. New York: Marcel Dekker; 1999:165173.

3
Radenne F, Lamblin C, Vandezande LM, et al.: Quality of life in nasal polyposis. J Allergy Clin Immunol 1999, 104:7984.

This prospective study used the 36-item short form health survey questionnaire,
a generic health-related quality-of-life scale, to evaluate quality of life of patients
with nasal polyps. Nasal polyps were found to impair quality of life to a higher
degree than perennial allergic rhinitis, and either medical or surgical management improved quality of life.
4

Settipane GA, Chafee FH: Nasal polyps in asthma and rhinitis: a review of
6,037 patients. J Allergy Clin Immunol 1977, 59:1721.

Hedman J, Kaprio J, Poussa T, et al.: Prevalence of asthma, aspirin intolerance, nasal polyposis, and chronic obstructive pulmonary disease in a
population-based study. Int J Epidemiol 1999, 28:717722.

6
Lamblin C, Gosset P, Salez F, et al.: Eosinophilic airway inflammation in
nasal polyposis. J Allergy Clin Immunol 1999, 104:8592.

This prospective study demonstrated the existence of subclinical bronchial


inflammation in patients with nasal polyps and asymptomatic bronchial hyperresponsiveness. This finding was similar to those observed in patients with nasal
polyps and clinical asthma, supporting the idea that inflammatory diseases in the
upper and lower airway seem to represent a range of overlapping pathology.
7

Hadfield PJ, Rowe-Jones JM, Mackay IS: The prevalence of nasal polyps in
adults with cystic fibrosis. Clin Otolaryngol 2000, 25:1922.

Asero R, Bottazzi G: Hypersensitivity to molds in patients with nasal polyposis: a clinical study. J Allergy Clin Immunol 2000, 105:186188.

Pang YT, Eskici O, Wilson JA: Nasal polyposis: role of subclinical delayed
food hypersensitivity. Otolaryngol Head Neck Surg 2000, 122:298301.

10 Norlander T, Bronnegard M, Stierna P: The relationship of nasal polyps,


infection, and inflammation. Am J Rhinol 1999, 13:349535.

A good review of the role of infectious and noninfectious inflammation in the


pathogenesis of nasal polyps.
11

Lee CH, Lee KS, Rhee CS, et al.: Distribution of RANTES and interleukin-5
in allergic nasal mucosa and nasal polyps. Ann Otol Rhinol Laryngol 1999,
108:594598.

12 Kramer MF, Rasp G: Nasal polyposis: eosinophils and interleukin-5. Allergy


1999, 54:669680.

Extensive review of the role of eosinophils and cytokines, especially interleukin-5,


in the pathogenesis of nasal polyps.
13

Nakagawa T, Yamane H, Shigeta T, et al.: Interaction between fibronectin


and eosinophils in the growth of nasal polyps. Laryngoscope 1999,
109:557561.

14

Coste A, Brugel L, Maitre B, et al.: Inflammatory cells as well as epithelial


cells in nasal polyps express vascular endothelial growth factor. Eur Respir
J 2000, 15:367372.

15

Gungor A, Baroody FM, Naclerio RM, et al.: Decreased neuropeptide


release may play a role in the pathogenesis of nasal polyps. Otolaryngol
Head Neck Surg 1999, 121:585590.

16

Fang SY, Yang BC: Overexpression of Fas-ligand in human nasal polyps.


Ann Otol Rhinol Laryngol 2000, 109:267270.

17

Molnar-Gabor E, Endreffy E, Rozsasi A: HLA-DRB1, -DQA1, and -DQB1


genotypes in patients with nasal polyposis. Laryngoscope 2000,
110:422425.
This study showed that one of the possible pathogeneses of nasal polyp is
genetic predisposition.
18

Schmid M, Gode U, Schafer D, et al.: Arachidonic acid metabolism in nasal


tissue and peripheral blood cells in aspirin intolerant asthmatics. Acta
Otolaryngol 1999, 119:277280.

19

Gosepath J, Hoffmann F, Schafer D, et al.: Aspirin intolerance in patients with


chronic sinusitis. ORL J Otorhinolaryngol Relat Spec 1999, 61:146150.

20

Picado C, Fernandez-Morata JC, Juan M, et al.: Cyclooxygenase-2 mRNA


is downexpressed in nasal polyps from aspirin-sensitive asthmatics. Am J
Respir Crit Care Med 1999, 160:291296.

Nasal polyps Assanasen and Naclerio 35

21

Kim SS, Kim KS, Lee JG, et al.: Levels of intracellular protein and messenger RNA of mucin and lysozyme in normal human nasal and polyp epithelium. Laryngoscope 2000, 110:276280.

22

Morinaka S, Nakamura H: Inflammatory cells in nasal mucosa and nasal


polyps. Auris Nasus Larynx 2000, 27:5964.

23

Nonaka M, Pawankar R, Saji F, et al.: Eotaxin synthesis by nasal polyp


fibroblasts. Acta Otolaryngol 1999, 119:816820.

24

Nonaka M, Pawankar R, Saji F, et al.: Distinct expression of RANTES and


GM-CSF by lipopolysaccharide in human nasal fibroblasts but not in other
airway fibroblasts. Int Arch Allergy Immunol 999, 119:314321.

44 Denyer S: Pharmaceutical properties of fluticasone propionate nasal drops:


a new formulation. Allergy 1999, 54(suppl 53):1720.

This paper describes the microbiologic quality, drug stability, reproducible drug
delivery, and quality controls of topical corticosteroid nasal drops, which is
another effective treatment option for patients with nasal polyposis.

25

Denburg J: Cytokines and inflammatory cells. In Nasal Polyposis: An


Inflammatory Disease and Its Treatment. Edited by Mygind N, Lildholdt T.
Copenhagen: Munksgaard; 1997:7887.

45

Daley-Yates PT, McAllister T: Systemic bioavailability of fluticasone propionate administered as nasal drops (FP-drops) and aqueous nasal spray
formulations (FPANS). Allergy 1998, 53(suppl 43):158.

46

Gazis AG, Homer JJ, Henson DB, et al.: The effect of six weeks topical
nasal betamethasone drops on the hypothalamo-pituitary-adrenal axis and
bone turnover in patients with nasal polyposis. Clin Otolaryngol 1999,
24:495498.

47

Mabry RL, Mabry CS: Allergic fungal sinusitis: the role of immunotherapy.
Otolaryngol Clin North America 2000, 33:433440.

26

27

Jahnsen FL, Haraldsen G, Haye R, et al.: Adhesion molecules and recruitment of eosinophils. In Nasal Polyposis: An Inflammatory Disease and Its
Treatment. Edited by Mygind N, Lildholdt T. Copenhagen: Munksgaard;
1997:8897.
Ozdemir R, Yorulmaz A, Kutlu R, et al.: Loss of nocturnal decline of blood
pressure in patients with nasal polyposis. Blood Pressure 1999,
8:165171.

28

Gold SM, Tami TA: Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997, 107:15861589.

29

Hahnel S, Ertl-Wagner B, Tasman AJ, et al.: Relative value of MR imaging


as compared with CT in the diagnosis of inflammatory paranasal sinus
disease. Radiology 1999, 210:171176.

30

Lund VJ, Kennedy DW: Staging for rhinosinusitis. Otolaryngol Head Neck
Surg 1997, 117:S35S40.

31

Mackay IS, Lund VJ: Imaging and staging. In Nasal Polyposis: An


Inflammatory Disease and Its Treatment. Edited by Mygind N, Lildholdt T.
Copenhagen: Munksgaard; 1997:137144.

43 Weber R, Keerl R, Radziwill R, et al.: Videoendoscopic analysis of nasal


steroid distribution. Rhinology 1999, 37:6973.

This study investigated intranasal deposition of steroid by using a fluorescein


solution applied with metered pump bottles. Videoendoscopy showed that the
majority of the substance remained on the anterior portion of the nasal septum
and the head of the inferior turbinate. Only a small portion reached the middle
meatus, which is the important area for the management of nasal polyps.

48 Szczeklik A, Stevenson DD: Aspirin-induced asthma: advances in pathogenesis and management. J Allergy Clin Immunol 1999, 104:513.

A nice review of pathogenesis and the current trend of management of aspirininduced asthma.
49

Anon JB: Computer-aided endoscopic sinus surgery. Laryngoscope 1998,


108:949961.

50

Mendelson MG, Gross CW: Soft-tissue shavers in pediatric sinus surgery.


Otolaryngol Clin North Am 1997, 30:443449.

51

Setliff R, Parsons D: The hummer: new instrumentation for functional


endoscopic sinus surgery. Am J Rhinol 1994, 8:275278.

52

Zweig JL, Schaitkin BM, Fan CY, et al.: Histopathology of tissue samples
removed using the microdebrider technique: implications for endoscopic
sinus surgery. Am J Rhinol 2000, 14:2732.

53

Bernstein JM, Lebowitz RA, Jacobs JB: Initial report on postoperative


healing after endoscopic sinus surgery with the microdebrider. Otolaryngol
Head Neck Surg 1998, 118:800803.

54

Kennedy DW, Wright ED, Goldberg AN: Objective and subjective


outcomes in surgery for chronic sinusitis. Laryngoscope 2000, 110(suppl
94):2931.

32

Lildholdt T, Mygind N: Effect of corticosteroids on nasal polyps: evidence


from controlled trials. In Nasal polyposis: An Inflammatory Disease and Its
Treatment. Edited by Mygind N, Lildholdt T. Copenhagen: Munksgaard;
1997:160169.

33

Nonaka M, Pawankar R, Tomiyama S, et al.: A macrolide antibiotic,


roxithromycin, inhibits the growth of nasal polyp fibroblasts. Am J Rhinol
1999, 13:267272.

34

Kanai N, Denburg J, Jordana M, et al.: Nasal polyp inflammation: effect of


topical nasal steroid. Am J Respir Crit Care Med 1994, 150:10941100.

35

Ogata Y, Okinaka Y, Takahashi M: Detection of activated eosinophils in


nasal polyps of an aspirin-induced asthma patient. Rhinology 1999,
37:1620.

55

Holmberg K, Juliusson S, Balder B, et al.: Fluticasone propionate aqueous


nasal spray in the treatment of nasal polyposis. Ann Allergy Asthma
Immunol 1997, 78:270276.

36

Tingsgaard PK, Bock T, Larsen PL, et al.: Topical budesonide treatment


reduces endothelial expression of intercellular adhesion molecules (vascular cell adhesion molecule-1 and P-selectin) and eosinophil infiltration in
nasal polyps. Acta Otolaryngol 1999, 19:362368.

56

Lund VJ, Flood J, Sykes AP, et al.: Effect of fluticasone in severe polyposis.
Arch Otolaryngol Head Neck Surg 1998, 124:513518.

57

Irifune M, Ogino S, Harada T, et al.: Topical treatment of nasal polyps with


a beclomethasone dipropionate powder preparation. Auris Nasus Larynx
1999, 26:4955.

58

Lildholt T, Rundcrantz H, Lindqvist N: Efficacy of topical corticosteroid


powder for nasal polyps: a double-blind, placebo-controlled study of
budesonide. Clin Otolaryngol 1995, 20:2630.

59

Lildholdt T, Fogstrup J, Gammelgaard N, et al.: Management of nasal


polyps by steroid nose drops. Am J Rhinol 1991, 5:13.

60

Citardi MJ, Kuhn FA: Endoscopically guided frontal sinus beclomethasone


instillation for refractory frontal sinus/recess mucosal edema and polyposis.
Am J Rhinol 1998, 12:179182.

37

Hamilos DL, Thawley SE, Kramper MA, et al.: Effect of intranasal fluticasone on cellular infiltration, endothelial adhesion molecule expression, and
proinflammatory cytokine mRNA in nasal polyp disease. J Allergy Clin
Immunol 1999, 103:7987.
This study showed a differential sensitivity of various inflammatory components
of nasal polyps to 4-week treatment with a topical nasal steroids. The steroidinsensitive inflammatory components may account for the partial reduction in the
size of nasal polyp after intranasal steroid treatment.
38

Jahnsen FL, Haye R, Gran E, et al.: Glucocorticosteroids inhibit mRNA


expression for eotaxin, eotaxin-2, and monocyte-chemotactic protein-4 in
human airway inflammation with eosinophilia. J Immunol 1999,
163:15451551.

39

Rudack C, Bachert C, Stoll W: Effect of prednisolone on cytokine synthesis in nasal polyps. J Interferon Cytokine Res 1999, 19:10311035.

40

Saunders MW, Wheatley AH, George SJ, et al.: Do corticosteroids induce


apoptosis in nasal polyp inflammatory cells? In vivo and in vitro studies.
Laryngoscope 1999, 109:785790.

41

Leung DYM, Hamilos DL, Thawley SE, et al.: Expression of GR in nasal


polyps and its relationship to glucocorticoid responsiveness. J Allergy Clin
Immunol 1998, 101:S45.

42

Naclerio RM, Mackay I: Guidelines for the management of nasal polyposis.


In Nasal Polyposis: An Inflammatory Disease and Its Treatment. Edited by
Mygind N, Lildholdt T. Copenhagen: Munksgaard; 1997:177180.

61

Penttila M, Poulsen P, Hollingworth K, et al.: Dose-related efficacy and


tolerability of fluticasone propionate nasal drops 400 microgram once daily
and twice daily in the treatment of bilateral nasal polyposis: a placebocontrolled randomized study in adult patients. Clin Exp Allergy 2000,
30:94102.
This double-blind, placebo-controlled study demonstrated the effectiveness of
FPNDs in the reduction of polyp size and in improving nasal blockage in 142
adult patients.
62

Van Camp P, Clement PAR: Results of oral steroid treatment in nasal polyposis. Rhinology 1994, 32:59.

63

Lildholdt T, Rundccrantz H, Bende M, et al.: Glucocorticoid treatment for


nasal polyps: a study of budesonide powder and depot-steroid injection.
Arch Otolaryngol Head Neck Surg 1997, 123:595600.

36 Nose and paranasal sinuses

64

Damm M, Jungehulsing M, Eckel HE, et al.: Effects of systemic steroid


treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging. Otolaryngol Head Neck Surg 1999, 120:517523.

77

Abdel-Hak B, Gunkel A, Kanonier G, et al.: Ciliary beat frequency, olfaction


and endoscopic sinus surgery. ORL J Otorhinolaryngol Relat Spec 1998,
60:202205.

65

Parnes SM, Chuma AV: Acute effects of antileukotrienes on sinonasal polyposis and sinusitis. Ear Nose Throat J 2000, 79:1820.

78

66

Ulualp SO, Sterman BM, Toohill RJ: Antileukotriene therapy for the relief of
sinus symptoms in aspirin triad disease. Ear Nose Throat J 1999,
78:604606.

Hafner B, Davris S, Riechelmann H, et al.: Endonasal sinus surgery


improves mucociliary transport in severe chronic sinusitis. Am J Rhinol
1997, 11:271274.

79

Kaluskar SK: Pre- and postoperative mucociliary clearance in functional


endoscopic sinus surgery. Ear Nose Throat J 1997, 76:884886.

67

Kennedy D: Prognostic factors, outcomes, and staging in ethmoid sinus


surgery. Laryngoscope 1992, 102:118.

80

Elwany S, Hisham M, Gamaee R: The effect of endoscopic sinus surgery


on mucociliary clearance in patients with chronic sinusitis. Eur Arch
Otorhinolaryngol 1998, 255:511514.

81

Delak KW, Stoll W: Olfactory function after functional endoscopic sinus


surgery for chronic sinusitis. Rhinology 1998, 36:1519.

82

Shin SH, Park JY, Sohn JH: Clinical value of olfactory function tests after
endoscopic sinus surgery: a short-term result. Am J Rhinol 1999,
13:6366.

83

Senior BA, Kennedy DW, Tanabodee J, et al.: Long-term impact of functional endoscopic sinus surgery on asthma. Otolaryngol Head Neck Surg
1999, 121:6668.

84

Ikeda K, Tanno N, Tamura G, et al.: Endoscopic sinus surgery improves


pulmonary function in patients with asthma associated with chronic sinusitis. Ann Otol Rhinol Laryngol 1999, 108:355359.

85

Dunlop G, Scadding GK, Lund VJ: The effect of endoscopic sinus surgery
on asthma: management of patients with chronic rhinosinusitis, nasal polyposis, and asthma. Am J Rhinol 1999, 13:261265.

68

Sobol SE, Wright ED, Frenkiel S: One-year outcome analysis of functional endoscopic sinus surgery for chronic sinusitis. J Otolaryngol 1998, 27:252257.

69

Dursun E, Bayiz U, Korkmaz H, et al.: Follow-up results of 415 patients


after endoscopic sinus surgery. Eur Arch Otorhinolaryngol 1998,
255:504510.

70

Hebert RL, Bent JP: Meta-analysis of outcomes of pediatric functional


endoscopic sinus surgery. Laryngoscope 1998, 108:796799.

71

Senior BA, Kennedy DW, Tanabodee J, et al.: Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998, 108:151157.

72

Sharp HR, Rowe-Jones JM, Mackay IS: The outcome of endoscopic sinus
surgery: correlation with computerized tomography score and systemic
disease. Clin Otolaryngol 1999, 24:3942.

73

Mostafa BE, El Fiky L, Sallam FA: Simple clinical system for the prediction
of recurrence of nasal polyps. Auris Nasus Larynx 1999, 26:165168.

74

Metson RB, Gliklich RE: Clinical outcomes in patients with chronic sinusitis. Laryngoscope 2000, 110(suppl 94):2428.

75

Keles N, Ilicali OC, Deger K: Objective and subjective assessment of nasal


obstruction in patients undergoing endoscopic sinus surgery. Am J Rhinol
1998, 12:307309.

86

Amar YG, Frenkiel S, Sobol SE: Outcome analysis of endoscopic sinus


surgery for chronic sinusitis in patients having Samters triad. J Otolaryngol
2000, 29:712.

76

Rowe-Jones JM, Mackay IS: A prospective study of olfaction following


endoscopic sinus surgery with adjuvant medical treatment. Clin
Otolaryngol 1997, 22:377381.

87

Nakamura H, Kawasaki M, Higuchi Y, et al.: Effects of sinus surgery on


asthma in aspirin triad patients. Acta Otolaryngol 1999, 119:592598.